Botox use in Face and Head

Botulinum toxin (BoNT) acts by:

Presynaptic inhibition at neuromuscular junctions → blocks acetylcholine (ACh) release

Cleaves SNARE proteins (SNAP-25, VAMP, syntaxin) → prevents vesicle fusion

Effects last 3-6 months (until nerve terminals regenerate)

A. Chronic Migraine

Injection Sites: 31-39 sites across frontal, temporal, occipital, and cervical muscles

Dose: 155-195 units (Botox®) q12 weeks

Efficacy: ~50% reduction in headache days/month

B. Spasticity (Post-Stroke, CP, MS)

Targets: Gastrocnemius (foot drop), biceps (flexor spasticity), adductors

Dose: 50-400 units per muscle (individualized)

Combines with PT/OT for best outcomes

C. Dystonia

Cervical dystonia (torticollis): Sternocleidomastoid, splenius capitis

Blepharospasm: Orbicularis oculi

Writer’s cramp: Forearm flexors

D. Hyperhidrosis (Excessive Sweating)

Palmar/axillary: 50-100 units per area

Effect: Anhidrosis for 4-12 months

OFF Label Use

Trigeminal Neuralgia (masseter/temporalis injections)

Neurogenic Detrusor Overactivity (bladder injections)

Tremor (refractory essential tremor, dystonic tremor)

Bruxism (masseter injections)

4. Practical Considerations

Peak Effect: 2-4 weeks post-injection

Adverse Effects:

Local weakness (e.g., ptosis in blepharospasm)

Dysphagia (if neck muscles injected)

Dry mouth (migraine protocol)

Contraindications:

Myasthenia gravis, ALS, Lambert-Eaton syndrome

Allergy to BoNT components

5. Future Directions

Newer Toxins: IncobotulinumtoxinA (longer duration)

Non-motor Applications: Depression (facial feedback hypothesis), neuropathic pain

Source: A.R. Yassin, MD

Mayo Clinic Q and A: Botox for wrinkles - is it safe? - Mayo ...

Author

Paddy Kalish OD, JD and B.Arch Author and Blogger

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